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CROUP
GENERAL FEATURES
• The term croup describes respiratory conditions, such as laryngitis, laryngotracheitis, laryngotracheobronchitis, or spasmodic croup, that manifest as inflammation of the larynx, trachea, and/or bronchi. Croup is the most common cause of stridor in children.
• Hallmark features include a barking, seallike cough and inspiratory stridor. Hoarseness may or may not be present and is more common in adults and older children.
• Croup is the result of an acute viral infection that is most commonly caused by parainfluenza virus type I, but other viruses may cause the condition. Bacterial infections may occur secondarily.
• Occurs most commonly in the late fall through early spring.
• Children aged 6 months to 5 years are most often affected, with the most severe symptoms manifesting in children aged 1 to 3 years.
CLINICAL ASSESSMENT
• Keep patients as comfortable as possible during the physical examination because agitation or crying exacerbates symptoms.
• Parents may describe a prodrome of nonspecific symptoms including rhinorrhea, sore throat, cough, and low-grade fever, then the development of the classic barking cough and inspiratory stridor.
• Cough may awaken patients, particularly at night when symptoms frequently worsen.
• Patients may demonstrate prolonged inspiration and inspiratory stridor. Presence of fine crackles indicates lower airway involvement.
• Patency of the patient's airway and the ability to maintain effective ventilation and oxygenation must be evaluated.
DIAGNOSIS
• The Westley score may help classify the severity of disease. It evaluates inspiratory stridor, retractions, air entry, cyanosis, and level of consciousness.
• If the diagnosis is unclear, anteroposterior and lateral neck radiographs may help, particularly to rule out epiglottitis or foreign body obstruction.
TREATMENT
• For mild to moderate disease, symptomatic measures, such as antipyretics, hydration, and inhalation of humidified air, may be sufficient.
• Patients with oxygen saturation less than 92% may need oxygen.
• A single dose of dexamethasone (0.15 mg/kg) given IV, IM, or orally within 4 to 24 hours after onset of symptoms has been shown to decrease inflammation and laryngeal edema.
• Nebulized racemic epinephrine is reserved for moderate to severe disease.
• Antibiotics are not indicated except in the case of a secondary bacterial infection.
• In severe cases, endotracheal intubation and respiratory support may be indicated. JAAPA
Dawn Colomb-Lippa is professor of physician assistant studies at Quinnipiac University, Hamden, Connecticut. Amy Klingler practices in primary care at the Salmon River Clinic, Stanley, Idaho. The authors are department editors for the Quick Recertification Series and members of the JAAPA editorial board. They have indicated no relationships to disclose relating to the content of this article.
QUESTION & ANSWER
1. Your patient has mild disease and can be treated as an outpatient. Which of the following is not a recommended outpatient treatment?
a. Antipyretics
b. Hydration
c. Amoxicillin, 80 to 90 mg/kg/d,
divided in two doses for 10 days
d. A single dose of dexamethasone,
0.15 mg/kg
Answer: c
Explanation: Antibiotics are not indicated for the treatment of croup. Supportive measures are the mainstay of treatment; however, single dose corticosteroids may be of benefit in the outpatient population.